Improving the efficiency of integrated cancer screening delivery across multiple cancers: case studies from Idaho, Rhode Island, and Nebraska

BACKGROUND

Three current and former awardees of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program launched integrated cancer screening strategies to better coordinate multiple cancer screenings (e.g., breast, cervical, colorectal). By integrating the strategies, efficiencies of administration and provision of screenings can be increased and costs can be reduced. This paper shares findings from these strategies and describes their effects.

METHODS

The Idaho Department of Health and Welfare developed a Baseline Assessment Checklist for six health systems to assess the current state of policies regarding cancer screening. We analyzed the checklist and reported the percentage of checklist components completed. In Rhode Island, we collaborated with a nurse-patient navigator, who promoted cancer screening, to collect details on patient navigation activities and program costs. We then described the program and reported total costs and cost per activity. In Nebraska, we described the experience of the state in administering an integrated contracts payment model across colorectal, breast, and cervical cancer screening and reported cost per person screened. Across all awardees, we interviewed key stakeholders.

RESULTS

In Idaho, results from the checklist offered guidance on areas for enhancement before integrated cancer screening strategies, but identified challenges, including lack of capacity, limited staff availability, and staff turnover. In Rhode Island, 76.1% of 1023 patient navigation activities were for colorectal cancer screening only, with a much smaller proportion devoted to breast and cervical cancer screening. Although the patient navigator found the discussions around multiple cancer screening efficient, patients were not always willing to discuss all cancer screenings. Nebraska changed its payment system from fee-for-service to fixed cost subawards with its local health departments, which integrated cancer screening funding. Screening uptake improved for breast and cervical cancer but was mixed for colorectal cancer screening.

CONCLUSIONS

The results from the case studies show that there are barriers and facilitators to integrating approaches to increasing cancer screening among primary care facilities. However, more research could further elucidate the viability and practicality of integrated cancer screening programs.

Development of a Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions in Primary Care Clinics

Evidence-based interventions, including provider assessment and feedback, provider reminders, patient reminders, and reduction of structural barriers, improve colorectal cancer screening rates. Assessing primary care clinics' readiness to implement these interventions can help clinics use strengths, identify barriers, and plan for success. However, clinics may lack tools to assess readiness and use findings to plan for successful implementation. To address this need, we developed the Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions (Field Guide) for the Centers for Disease Control and Prevention's (CDC's) Colorectal Cancer Control Program (CRCCP). We conducted a literature review of evidence and existing tools to measure implementation readiness, reviewed readiness tools from selected CRCCP award recipients (n = 35), and conducted semi-structured interviews with key informants (n = 8). We sought feedback from CDC staff and recipients to inform the final document. The Field Guide, which is publicly available online, outlines 4 assessment phases: 1) convene team members and determine assessment activities, 2) design and administer the readiness assessment, 3) evaluate assessment data, and 4) develop an implementation plan. Assessment activities and tools are included to facilitate completion of each phase. The Field Guide integrates implementation science and practical experience into a relevant tool to bolster clinic capacity for implementation, increase potential for intervention sustainability, and improve colorectal cancer screening rates, with a focus on patients served in safety net clinic settings. Although this tool was developed for use in primary care clinics for cancer screening, the Field Guide may have broader application for clinics and their partners for other chronic diseases.

The Effectiveness and Cost to Improve Colorectal Cancer Screening in a Federally Qualified Homeless Clinic in Eastern Kentucky

The objective of this study was to analyze the effectiveness and cost of patient incentives, together with patient navigation and patient reminders, to increase fecal immunochemical test (FIT) kit return rates and colorectal cancer screening uptake in one federally qualified health center (FQHC) in Appalachia. This FQHC is a designated homeless clinic, as 79.7% of its patient population are homeless. We collected process, outcome, and cost data from the FQHC for two time periods: usual care (September 2016-August 2017) and implementation (September 2017-September 2018). We reported the FIT kit return rate, the increase in return rate, and the additional number of individual screens. We also calculated the incremental cost per additional screen. The patient incentive program, with patient navigation and patient reminders, increased the number of FIT kits returned from the usual care period to the implementation period. The return rate increased by 25.9 percentage points (from 21.7% to 47.6%) with an additional 91 people screened at an incremental cost of $134.61 per screen. A patient incentive program, together with the assistance of patient navigators and supplemented with patient reminders, can help improve CRC screening uptake among vulnerable and homeless populations.

0044 Association Between Chronotype and Circulating Levels of Interleukin-6 in Colorectal Cancer Patients: Preliminary Results from the ColoCare Study

Introduction

Accumulating evidence suggests that chronotype, i.e., circadian topology of an individual indicating morning or evening type, is associated with inflammation. To date, no study has examined the relationship between chronotype and inflammation in colorectal cancer patients. We investigated the associations between chronotype and inflammatory and angiogenesis biomarkers in colorectal cancer patients.

Methods

We used pre-surgery serum samples from n=67 newly diagnosed colorectal cancer patients (stage I-IV) recruited at the ColoCare Study site in Heidelberg, Germany. The ColoCare Study is an ongoing, international, multisite, prospective cohort study in colorectal cancer patients. Inflammatory and angiogenesis biomarkers [c-reactive protein (CRP), interleukin (IL)-6, IL-8, monocyte chemoattractant protein-1 (MCP-1), soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1)] were measured at the Huntsman Cancer Institute, USA using the Meso Scale Discovery platform and were log transformed. Chronotype was assessed prior to surgery with the reduced Morningness-Eveningness Questionnaire (rMEQ; scale 4–25; a higher score indicates more morning-type). Patients were dichotomized, based on the median values for rMEQ, into 2 groups: rMEQ-low (score≤16.0; n=35; indicating more evening-type) or rMEQ-high (score>16.0; n=32; indicating more morning-type).

Results

Using Mann-Whitney U test, we observed that rMEQ-low group (i.e., more evening-type) compared to rMEQ-high group (i.e., more morning-type) had approx. two times significantly higher levels of log transformed IL-6 (mean=2.24 vs. 1.30; U=382.0; Z=-2.23; p=0.03), but not for other inflammatory or angiogenesis biomarkers. This association between chronotype and IL-6 was maintained even after adjusting for age, sex, tumor stage, tumor site, and sleep duration using a generalized estimating equations model (adjusted mean difference=1.10; 95% confidence interval=0.33, 1.88; p=0.01; effect size, Cohen’s d=0.69).

Conclusion

These preliminary findings suggest that the evening chronotype is associated with increased IL-6 inflammatory biomarker in colorectal cancer patients. Further research is needed to confirm and understand the mechanistic underpinnings of the observed results.

Support

Funding: NCI U01 CA206110, R01 CA189184, and R01 CA207371.

In their own words: A qualitative study of the psychosocial concerns of posttreatment and long-term lung cancer survivors

Although lung cancer is the deadliest type of cancer, survival rates are improving. To address the dearth of literature about the concerns of lung cancer survivors, the authors conducted 21 in-depth interviews with lung cancer survivors that focused on experiences during diagnosis, treatment, and long-term survivorship. Emergent themes included feeling blamed for having caused their cancer, being stigmatized as throwaways, and long-term survivors' experiencing surprise that they are still alive, given poor overall survival rates. Survivors also desired increased public support. It is imperative for healthcare and public health professionals to learn more about needs of this population.

High-resolution ultrasonography of peripheral nerves: measurements on 14 nerve segments in 56 healthy subjects and reliability assessments

PURPOSE

The aim of this study was to assess different aspects of reliability in high-resolution ultrasonography (HRUS) of the peripheral nerves and to establish reference values for the most frequently examined nerve segments.

MATERIALS AND METHODS

A nerve size parameter, the cross-sectional area (CSA) of the C5, C6 and C7 cervical roots, the median, ulnar, radial, superficial radial, peroneal, tibial, and the sural nerves was measured using HRUS at a total of 14 predefined anatomical sites in two different cohorts of healthy subjects (n = 56), and the inter-rater, intra-rater and inter-equipment reliability of measurements was assessed.

RESULTS

The mean CSA of the 14 nerve segments ranged from 2 to 10 mm(2). The intra-rater, inter-rater and inter-equipment reliability was high with intraclass correlation coefficients of 0.93, 0.98, and 0.86, respectively. The CSA values showed no consistent correlation with age, height, and body weight, but males had significantly larger values than females for nerve segments on the arm after correcting for age, weight and height in multivariate analysis. CSA values did not differ when two independent cohorts were compared.

CONCLUSION

Peripheral nerve ultrasonography is a reliable and reproducible diagnostic method in the hands of experienced examiners. Normal values for several upper and lower extremity nerves are provided by our study.

Vici syndrome associated with sensorineural hearing loss and evidence of neuromuscular involvement on muscle biopsy

Vici syndrome is a rare, genetically unresolved congenital multisystem disorder comprising agenesis of the corpus callosum, cataracts, immunodeficiency, cardiomyopathy, and hypopigmentation. An associated neuromuscular phenotype has not previously been described in detail. We report on an infant with clinical features suggestive of Vici syndrome and additional sensorineural hearing loss. Muscle biopsy revealed several changes including markedly increased variability in fiber size, increased internal nuclei, and abnormalities on Gomori trichrome and oxidative stains, raising a wide differential diagnosis including neurogenic atrophy, centronuclear myopathy (CNM) or a metabolic (mitochondrial) cytopathy. Respiratory chain enzyme studies, however, were normal and sequencing of common CNM-associated genes did not reveal any mutations. This case expands the clinical spectrum of Vici syndrome and indicates that muscle biopsy ought to be considered in infants presenting with suggestive clinical features. In addition, we suggest that Vici syndrome is considered in the differential diagnosis of infants presenting with congenital callosal agenesis and that additional investigation has to address the possibility of associated ocular, auditory, cardiac, and immunologic involvement when this radiologic finding is present.

Search for muon-neutrino to electron-neutrino transitions in MINOS

This Letter reports on a search for nu(mu) --> nu(e) transitions by the MINOS experiment based on a 3.14x10(20) protons-on-target exposure in the Fermilab NuMI beam. We observe 35 events in the Far Detector with a background of 27+/-5(stat)+/-2(syst) events predicted by the measurements in the Near Detector. If interpreted in terms of nu(mu) --> nu(e) oscillations, this 1.5sigma excess of events is consistent with sin2(2theta(13)) comparable to the CHOOZ limit when |Delta m2|=2.43x10(-3) eV2 and sin2(2theta(23))=1.0 are assumed.

Search for active neutrino disappearance using neutral-current interactions in the MINOS long-baseline experiment

We report the first detailed comparisons of the rates and spectra of neutral-current neutrino interactions at two widely separated locations. A depletion in the rate at the far site would indicate mixing between nu(mu) and a sterile particle. No anomalous depletion in the reconstructed energy spectrum is observed. Assuming oscillations occur at a single mass-squared splitting, a fit to the neutral- and charged-current energy spectra limits the fraction of nu(mu) oscillating to a sterile neutrino to be below 0.68 at 90% confidence level. A less stringent limit due to a possible contribution to the measured neutral-current event rate at the far site from nu(e) appearance at the current experimental limit is also presented.

Testing Lorentz invariance and CPT conservation with NuMI neutrinos in the MINOS near detector

A search for a sidereal modulation in the MINOS near detector neutrino data was performed. If present, this signature could be a consequence of Lorentz and CPT violation as predicted by the effective field theory called the standard-model extension. No evidence for a sidereal signal in the data set was found, implying that there is no significant change in neutrino propagation that depends on the direction of the neutrino beam in a sun-centered inertial frame. Upper limits on the magnitudes of the Lorentz and CPT violating terms in the standard-model extension lie between 10(-4) and 10(-2) of the maximum expected, assuming a suppression of these signatures by a factor of 10(-17).

Measurement of neutrino oscillations with the MINOS detectors in the NuMI beam

This Letter reports new results from the MINOS experiment based on a two-year exposure to muon neutrinos from the Fermilab NuMI beam. Our data are consistent with quantum-mechanical oscillations of neutrino flavor with mass splitting |Deltam2| = (2.43+/-0.13) x 10(-3) eV2 (68% C.L.) and mixing angle sin2(2theta) > 0.90 (90% C.L.). Our data disfavor two alternative explanations for the disappearance of neutrinos in flight: namely, neutrino decays into lighter particles and quantum decoherence of neutrinos, at the 3.7 and 5.7 standard-deviation levels, respectively.

Facilitators and challenges to start-up of the colorectal cancer screening demonstration program

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) funded the Colorectal Cancer Screening Demonstration Program in 2005. To assess the feasibility of providing community-based colorectal cancer screening, CDC is conducting a multiple-case study as part of a larger evaluation effort. This article highlights key facilitators and challenges common to the five programs studied during the start-up period.

METHODS

The multiple-case study that includes all five program sites is being conducted during the 3-year program as part of process evaluation efforts. Data collection for program start-up occurred during August 2005 through September 2006. Data include approximately 70 interviews with program staff and stakeholders, document review, and observations. Both case-specific and cross-case analyses were conducted.

RESULTS

On the basis of the cross-case analysis, we identified four factors that facilitated program start-up and four factors that challenged program start-up. Facilitating factors included 1) pre-existing program infrastructure, 2) partnerships, 3) clinical expertise, and 4) program champions. Factors challenging program start-up included 1) contracts with endoscopists, 2) resources for treating medical complications of screening and for cancer treatment, 3) administrative barriers, and 4) resource limitations. Additionally, preplanning was critical, allowing programs to efficiently initiate activities once funds became available.

CONCLUSION

The most important facilitator identified was the ability to build on pre-existing infrastructure, which provided experienced staff, partnerships, and provider relationships, as well as aided program integration with other chronic disease programs. Results also suggest that substantial planning and partnership development can begin before funds are secured to implement a colorectal cancer screening program.

Start-up of the colorectal cancer screening demonstration program

INTRODUCTION

In 2005, the Centers for Disease Control and Prevention funded five sites to implement the Colorectal Cancer Screening Demonstration Program (CRCSDP). An evaluation is being conducted that includes a multiple case study. Case study results for the start-up period, the time between initial funding and screening initiation, provide details about the program models and start-up process and reveal important lessons learned.

METHODS

The multiple case study includes all five CRCSDP sites, each representing a unique case. Data were collected from August 2005 through September 2006 from documents, observations, and more than 70 interviews with program staff and stakeholders.

RESULTS

Sites differed by geographic service area, screening modality selected, and service delivery structure. Program models were influenced by two factors: preexisting infrastructure and the need to adapt programs to fit local service delivery structures. Several sites modeled program components after their National Breast and Cervical Cancer Early Detection Program. Medical advisory boards convened by all sites provided clinical support for developing program policies and quality assurance plans. Partnerships with comprehensive cancer control programs facilitated access to financial and in-kind resources.

CONCLUSION

The program models developed by the CRCSDP sites offer a range of prototypes. Case study results suggest benefits in employing a multidisciplinary staff team, assembling a medical advisory board, collaborating with local partners, using preexisting resources, designing programs that are easily incorporated into existing service delivery systems, and planning for adequate start-up time.

Best of the web in pathology: a practical guide to finding specific pathology resources on the internet

BACKGROUND

Although a large number of pathology-specific websites (PSWs) are accessible on the internet, the potential use of PSWs is relatively unknown among pathologists. As a PSW-directory does not exist, it may be difficult to find certain resources that are scattered over the internet.

AIMS

To critically revisit PSWs in order to create a collection of selected websites that may be useful for practising pathologists worldwide.

METHODS

Using special medical databases and link collections, extensive search for PSWs was performed on the world wide web. Each website was evaluated with regard to content and practical use for pathologists.

RESULTS

PSWs contain electronic training manuals, journals, case collections, photo-archives, link directories, or slide collections of virtual microscopy. PSWs offer lavishly illustrated education material for undergraduates and postgraduates in pathology, but may also be very useful as reference books or as an instrument of continuing medical education for experienced pathologists. The paper shows how to find PSWs, and presents an annotated list of 100 of the best PSWs.

CONCLUSIONS

PSWs as a whole form a heterogeneous patchwork of information. It is suggested that a central catalogue listing all PSWs that are available worldwide be established. This database would enable pathologists to have immediate access to all up-to-date pathology-specific resources on the internet, without the need to perform any laborious web research for themselves. It is hoped that in the future, the repertoire of on-line resources in pathology will be systematically perfected. The internet will then play a central role in the daily practice of pathologists as a medium of information and communication.

Observation of muon neutrino disappearance with the MINOS detectors in the NuMI neutrino beam

This Letter reports results from the MINOS experiment based on its initial exposure to neutrinos from the Fermilab NuMI beam. The rates and energy spectra of charged current nu(mu) interactions are compared in two detectors located along the beam axis at distances of 1 and 735 km. With 1.27 x 10(20) 120 GeV protons incident on the NuMI target, 215 events with energies below 30 GeV are observed at the Far Detector, compared to an expectation of 336+/-14 events. The data are consistent with nu(mu) disappearance via oscillations with |Delta(m)2/32|=2.74 +0.44/-0.26 x10(-3)eV(2) and sin(2)(2theta(23))>0.87 (68% C.L.).

Successful transplantation of kidneys from a donor with myoglobinuric acute renal failure

The shortage of donor organs is reflected in the growing number of patients on the waiting list for kidney transplantation worldwide. It seems to be sensible to expand the scarce donor pool by the cautious use of extended donor criteria. Kidneys from a 21-year-old deceased donor road traffic accident victim who suffered acute renal failure (ARF) due to myolysis were transplanted. Both transplantations were successful after an initial period of delayed graft function. Therefore, kidneys from deceased donors with ARF should not be excluded for transplantation in general.

Low-grade T-cell lymphoma of the kidney and Waldenström's macroglobulinemia in a patient presenting with renal failure

Renal failure is rarely the presenting manifestation of non-Hodgkin's lymphoma. We describe the unusual case of a patient who presented with uremia due to lymphomatous infiltration of the kidney by a low-grade T-cell lymphoma. The diagnosis of lymphoma was made by renal biopsy. Extrarenal nodular or extra-nodular involvement could not be detected. However, simultaneously, a lymphoplasmacytic lymphoma was found on bone marrow biopsy associated with IgM paraproteinemia. To our knowledge, this is the first report of a renal T-cell lymphoma associated with Waldenström's macroglobulinemia.

AMPA receptor phosphorylation during synaptic plasticity

A widely studied example of vertebrate plasticity is LTP (long-term potentiation), the persistent synaptic enhancement that follows a brief period of coinciding pre- and post-synaptic activity. During LTP, different kinases, including CaMKII (calcium/calmodulin-dependent protein kinase II) and protein kinase A, become activated and play critical roles in induction and maintenance of enhanced transmission. Biochemical analyses have revealed several regulated phosphorylation sites in the AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptor subunits, GluR1 and GluR4. The regulated insertion of these receptors is a key event in the induction of LTP. Here, we discuss the phosphorylation of GluR1 and GluR4 and its role in receptor delivery and neuronal plasticity.

Continuous complete hematological and cytogenetic remission with molecular minimal residual disease 9 years after discontinuation of interferon-alpha in a patient with Philadelphia chromosome-positive chronic myeloid leukemia

Interferon-alpha has been used as standard therapy for patients with Philadelphia-positive chronic myeloid leukemia (CML) for more than 20 years. Recently randomized trials have shown a superiority of the tyrosine kinase inhibitor imatinib in respect to its efficacy to induce complete hematological and cytogenetic remissions and more importantly in overall survival. Although follow-up is much shorter for imatinib than for interferon-alpha, this data changed the treatment algorithms in this disease. At the end of the era of interferon-alpha as a single-drug first-line treatment for most patients we present a case report which exemplifies a rare but exciting property of interferon-alpha in CML: the induction of complete hematological and cytogenetic remissions which can persist over years after discontinuation of the drug. Hence, the enrollment of CML patients in clinical trials which explore a combination treatment of imatinib and interferon-alpha is warranted.

From micro to nano: properties and potential applications of micro- and nano-filled polymer ceramic composites in microsystem technology

In microsystem technology, four important material classes are established either for the generation or the replication of microstructured surfaces: silicon, polymers, metals and ceramics. Composite materials consisting of a polymer matrix and ceramic fillers show improved thermomechanical properties in comparison to polymers and can be introduced as a new additional material class. The substitution of micro-sized ceramic fillers by nano-sized ceramics in composites has a strong influence on the composite's physical properties: the reduction of ceramic particle size down to the nanometre scale results in an improved sinter activity owing to the large surface area. The fabrication of dense ceramics is simplified and can be used for a rapid prototyping of microstructured ceramic parts. The addition of nano-sized ceramics with particle sizes of <40 nm to polymers allows the manufacturing of transparent polymer based composites with modified refractive indices for use in polymer waveguides. The influence of the ceramic particle size, the ceramic content and different dispersion methods on the composite's physical properties are discussed.

Predominant mutation of codon 41 of the beta-catenin proto-oncogene in rat colon tumors induced by 1,2-dimethylhydrazine using a complete carcinogenic protocol

Constitutive activation of the wnt-signaling pathway plays an important role during both human and rat colon carcinogenesis and can be brought through mutations in either the adenomatous polyposis coli or the beta-catenin gene. Mutations found in the beta-catenin gene typically affect one out of four regulatory phosphorylation sites near the N-terminus of the beta-catenin protein. Whereas in human colon cancers, however, the majority of beta-catenin mutations directly alter threonine 41 or serine 45; the beta-catenin mutations found in chemically induced rat colon tumors seemed to cluster around codon 33 instead. Unlike previous studies, that have used relatively short-term (2-5 weeks) treatment with one of the alkylating agents 1,2,-dimethylhydrazine (DMH) or azoxymethane, we have investigated the mutational spectrum of the beta-catenin gene in a panel of rat colon tumors induced by long-term (20 weeks) DMH-treatment. We detected beta-catenin mutations in 12 of 33 (36%) tumors. Interestingly, only one of the beta-catenin mutations found affected the previously implicated codon 33 cluster region (Asp32Asn), whereas 11 of 12 (>90%) mutations represented identical C-->T transitions within codon 41 resulting in the common replacement of threonine by isoleucine. We propose a model in which codon 41 mutations bear higher oncogenic potential but are induced by DMH less frequently than mutations in the codon 33 cluster region. Consequently, only after sustained carcinogenic treatment, as is achieved in the long-term DMH-protocol, codon 41 mutations will be induced frequently enough to be present in all developing malignant lesions and, then, because of their higher oncogenic potential, these are selected for.

Presumptive copper deficiency in hand-reared captive pronghorn (Antilocapra americana) fawns

Presumptive copper deficiency was diagnosed in hand-reared captive pronghorn (Antilocapra americana) at the Los Angeles Zoo. Clinical signs, which were manifested in growing fawns, included anemia, anorexia, diarrhea, progressive paresis/recumbency, and aortic rupture. The range of serum copper concentrations in fawns born during the 1989 season (0.08-0.67 ppm) was below levels considered normal for domestic sheep and goats (0.7-2.0 ppm) and below concentrations measured in adult pronghorn (0.4-1.43 ppm). Copper sulfate supplementation of the hand-rearing formula, which was initiated in 1989, resulted in a significant increase in mean (+/- SD) serum copper levels from 0.45 +/- 0.18 ppm before supplementation to 0.68 +/- 0.05 ppm after supplementation (P < 0.05). Fawns born in subsequent seasons (April 1990-August 1993) continued to be supplemented with copper in the hand-rearing formula. Mean serum copper concentration from these fawns (0.68 +/- 0.22 ppm) was similar to the mean values from supplemented 1989 fawns and adult pronghorn in this herd (0.85 +/- 0.34 ppm; P > 0.05). No clinical signs of copper deficiency were detected in any fawns after supplementation was started. Analyses of the herd's diet revealed marginal dietary copper levels. Suspected dietary deficiency was confirmed by marginal tissue and serum copper concentrations in some of the herd's adult animals. Dietary copper levels were corrected to prevent future cases of clinical copper deficiency.